Akses terbuka
BMJ Open: first published as 10.1136/bmjopen-2013-003901 on 13 March 2014. Downloaded from
Untuk mengutip: Watts S, Leydon G, Birch
B, et al. Depresi dan kecemasan pada
kanker prostat: review sistematis dan
meta-analisis dari tingkat prevalensi. BMJ
Terbuka 2014; 4:
e003901. doi: 10,1136 /
bmjopen-2.013-003.901
▸ sejarah prapublikasi untuk kertas ini
tersedia secara online. Untuk melihat
file-file ini silakan kunjungi jurnal online
(http://dx.doi.org/10.1136/
bmjopen-2.013-003.901).
Menerima Agustus 2013 Revisi 21
Januari 2014 Diterima 24 Januari
2014 28
1 Primary Care & Ilmu
Kependudukan, Universitas
Southampton, Southampton,
Hampshire, UK
2 Departemen Urologi,
Southampton University
Hospitals NHS Trust,
Southampton, Hampshire, UK
3Departemen Matematika, Universitas
Southampton, Southampton,
Hampshire, UK
korespondensi ke
Profesor George Lewith;
glewith@scmrt.org.uk
Watts S, Leydon G, Birch B, et al. BMJ Terbuka 2014; 4: e003901. doi: 10,1136 / bmjopen-2.013-003.901
Depresi dan kecemasan pada kanker
prostat: review sistematis dan meta-analisis
tingkat prevalensi
Sam Watts, 1 Geraldine Leydon, 1 Brian Birch, 2 Philip Prescott, 3 Lily Lai, 1
Susan Eardley, 1 George Lewith 1
ABSTRAK
tujuan: Untuk secara sistematis meninjau literatur yang berkaitan dengan
prevalensi depresi dan kecemasan pada pasien dengan kanker prostat
sebagai fungsi dari tahap pengobatan.
Rancangan: review sistematis dan meta-analisis.
peserta: 4494 pasien dengan kanker prostat dari investigasi
penelitian utama.
Primer ukuran hasil: Prevalensi depresi klinis dan kecemasan
pada pasien dengan kanker prostat sebagai fungsi dari tahap
pengobatan.
hasil: Kami mengidentifikasi 27 penuh artikel jurnal yang memenuhi
kriteria inklusi untuk masuk ke meta-analisis menghasilkan ukuran sampel
dikumpulkan dari 4494 pasien. Meta-analisis dari tingkat prevalensi
diidentifikasi pretreatment, on-pengobatan dan pasca perawatan
prevalensi depresi dari 17,27% (95% CI 15,06% untuk
19,72%), 14,70% (95% CI 11,92% menjadi 17,99%) dan
18.44% (95% CI 15,18% menjadi 22,22%), masing-masing. Pretreatment,
on-pengobatan dan pasca perawatan prevalensi kecemasan adalah 27,04%
(95% CI 24,26% untuk
30,01%), 15,09% (95% CI 12,15% menjadi 18,60%) dan
18,49% (95% CI 13,81% menjadi 24,31%), masing-masing.
kesimpulan: Temuan kami menunjukkan bahwa prevalensi depresi dan
kecemasan pada pria dengan kanker prostat, seluruh spektrum
pengobatan, relatif tinggi. Mengingat penekanan tumbuh ditempatkan
pada kesintasan kanker, kami menganggap bahwa penelitian lebih lanjut
dalam bidang ini dijamin untuk memastikan bahwa tekanan psikologis
pada pasien dengan kanker prostat tidak terdiagnosis dan terobati.
PENGANTAR
Kanker prostat (PCa) merupakan bentuk umum paling
keganasan non-kulit didiagnosis pada pria Inggris. 1 Lebih
dari 36 000 kasus baru didiagnosis pada tahun 2007,
akuntansi selama hampir 25% dari total jumlah tahunan
diagnosis kanker laki-laki. 1 Dengan penuaan populasi
Inggris dan meningkatkan pemanfaatan PCa skrining
pada pria tanpa gejala, 2 tingkat kejadian PCa
diperkirakan akan terus meningkat dari tahun ke tahun. 1
Dalam terang seperti beban penyakit yang substansial dan
berkelanjutan, manajemen
Penelitian
Kekuatan dan keterbatasan penelitian ini
▪ Ini adalah meta-analisis pertama yang mendefinisikan sion depres-
dan prevalensi kecemasan khusus dalam kanker prostat.
▪ Data terbatas yang tersedia untuk pasien surveilans aktif dan
dengan penyakit metastasis.
▪ metodologi cross-sectional membuat sulit untuk menarik
kesimpulan yang pasti tentang sejarah dan perkembangan
kecemasan dan depresi selama perjalanan kanker pada
populasi ini.
ketahanan hidup isu-isu dalam PCa mengasumsikan penting
pentingnya. isu-isu seperti berputar di sekitar
perawatan yang efektif kualitas hidup (kualitas hidup)
sepanjang perjalanan kanker, dari diagnosis awal
melalui ketahanan hidup pasca perawatan.
Tambahan, itu
http://bmjopen.bmj.com/
National Cancer ketahanan hidup Initiative (NCSI)
didirikan fi ve tujuan utama dari perbaikan, pribadi dan
berpusat pada pasien perawatan di Inggris. 3 Salah satu
tujuan adalah kebutuhan untuk alamat lebih baik spesifik
yang fi c kekhawatiran psikologis yang terkait dengan
diagnosis dan pengobatan kanker. Depresi dan
kecemasan adalah dua kondisi psikologis yang paling
sering dialami dialami oleh penderita kanker 4 dan
berkaitan dengan efek samping psychophysiological unik
on February 5, 2020 by guest. Protected by copyright.
yang penting Encompass hasil pengobatan yang lebih
buruk, 5
peningkatan periode rawat inap 6 dan tingkat kematian yang
lebih tinggi. 7 Dengan kemajuan di ef pengobatan fi khasiat,
kanker semakin dipandang dan diperlakukan sebagai
penyakit kronis yang dapat dikelola secara efektif selama
bertahun-tahun. Mengingat umur panjang terkait dengan
lintasan PCa (lebih dari 70% pasien dengan PCa dapat
berharap untuk hidup selama 10 tahun atau lebih dari saat
diagnosis), adalah mungkin bahwa timbulnya tekanan
psikologis dalam populasi ini laki-laki bukan ancaman akut
yang berlalu dengan cepat tetapi satu kronis dengan puncak
dan palung keparahan yang terjadi pada tahap kunci dari
perjalanan kanker.
dari
1
 Akses terbuka
Basis penelitian mengevaluasi prevalensi depresi dan kecemasan
dalam PCa terus berkembang dan tubuh yang cukup besar penelitian
klinis yang relevan ada saat ini. Sayangnya, banyak data yang sangat
heterogen dan kualitas metodologi miskin dan belum dikenakan ketat
review sistematis dan
meta-analisis. Kurangnya sintesis membuatnya sangat dif fi
kultus untuk dokter dan bersekutu profesional kesehatan bekerja dengan PCa untuk
mengakses, menafsirkan dan menerapkan penelitian kunci fi Temuan untuk praktek
klinis mereka.
Hal ini belum jelas apa tahap pasien perjalanan kanker PCa fi nd yang
paling menyedihkan. Apakah ini dikenal, atau setidaknya lebih dipahami, itu
akan memungkinkan para profesional kesehatan untuk lebih proaktif dan
menyadari apa tahapan pasien pengobatan yang paling mungkin untuk
mengalami depresi dan kecemasan. Hal ini akan memungkinkan tim
kesehatan untuk risiko beradaptasi psikologis screening dan dukungan
proses mereka.
Meta-analisis ini dilakukan untuk mengatasi masalah ini dan
memberikan perkiraan dasar awal dari prevalensi depresi klinis dan
kecemasan pada pasien dengan PCa selama masing-masing dari tiga
tahap utama pengobatan kanker:
pretreatment, on-pengobatan dan
pasca perawatan.
METODE
Kriteria kelayakan
Studi yang menyelidiki spesifik yang fi prevalensi c depresi dan
kecemasan pada pasien dengan PCa di artikel jurnal penuh
dimasukkan. Studi yang dipublikasikan dalam prosiding konferensi,
penelitian kualitatif, komentar dan diskusi,
surat, buku, bab buku atau
penelitian yang tidak dipublikasikan dalam bahasa Inggris dikeluarkan.
studi yang memenuhi syarat dibatasi untuk penelitian yang berfokus
pada individu dengan con biopsi fi diagnosis rmed dari PCa. Jika pasien
dengan PCa dimasukkan dalam penyelidikan yang direkrut populasi
kanker campuran, penelitian ini wajib memiliki data tentang pasien
dengan PCa sebagai sub sampel yang berbeda dilaporkan. Hasil
utama untuk meta-analisis saat ini adalah prevalensi depresi dan
kecemasan. Dengan demikian, masuknya ke dalam meta-analisis
dibatasi untuk mereka studi yang dilaporkan PCa-spesifik fi Data c
prevalensi depresi dan kecemasan secara terpisah. Agar memenuhi
syarat untuk dimasukkan, setiap studi diminta untuk memberikan de
jelas fi Definisi perawatan PCa dilakukan oleh peserta penelitian dan
ketika perawatan seperti terjadi (yaitu, pengobatan yang belum
dilakukan, sedang dilakukan pada saat studi atau sudah selesai.
Untuk kategori yang terakhir, itu adalah persyaratan bahwa penulis
speci fi ed selang waktu sejak penghentian pengobatan).
analisis kuesioner
Masuk ke meta-analisis juga dibatasi untuk data yang dikumpulkan
dari kuesioner yang diberikan spesifik fi c, valid dan pengukuran
diandalkan depresi
2 Watts S, Leydon G, Birch B, et al. BMJ Terbuka 2014; 4: e003901. doi: 10,1136 / bmjopen-2.013-003.901
BMJ Open: first published as 10.1136/bmjopen-2013-003901 on 13 March 2014. Downloaded from
dan kecemasan. Untuk mengaktifkan ini, serangkaian kuesioner spesifik fi kriteria
inklusi c diciptakan terhadap yang semua kuesioner yang digunakan
dalam penelitian dapat dinilai; masing-masing kuesioner harus:
Memungkinkan tertentu yang fi c dan pengukuran independen depresi dan
kecemasan;
Memiliki informasi yang tersedia didirikan threshold (pengukuran)
untuk diagnosis depresi dan kecemasan;
Validitas masing-masing kuesioner harus telah dinilai dibandingkan
dengan mendirikan ' standar emas '
kuesioner;
Validitas internal dan reliabilitas masing-masing kuesioner harus
telah dinilai dan dianggap dapat diterima (uji - tes ulang).
Dua belas kuesioner yang memenuhi kriteria yang identi-
fi ed yang termasuk Kecemasan Rumah Sakit dan Skala Depresi,
Stait-Trait Anxiety Scale, Pusat Epidemiologi Studi Skala Depresi,
Gejala Checklist, Beck Depression Inventory,
Self-Rating Scale Anxiety,
Self-Penilaian Skala Depresi, Brief Gejala Persediaan, Wawancara
Composite Internasional diagnostik, Skala Kecemasan Memorial
untuk Kanker Prostat dan Efek Kanker Prostat pada Lifestyle Angket.
Mengidentifikasi bukti penelitian
pencarian data yang dilakukan antara Juni dan Agustus
2011. protokol pencarian kemudian jalankan Juni 2013 untuk memastikan
bahwa tidak ada data tambahan yang identi-
fi ed. Kami mencari enam database elektronik (OVID MEDLINE,
EMBASE, AMED, PsycINFO, CINAHL dan Web of Science) untuk artikel
http://bmjopen.bmj.com/
yang memenuhi kriteria dibahas sebelumnya menggunakan prespeci fi ed
MESH istilah yang termasuk Prostat Neoplasma (EXP) ' ATAU ' Kanker
prostat ' DAN ' Depresi (EXP) ' atau ' Kecemasan (EXP) ' atau
' tekanan psikologis (EXP ' atau ' Stres (EXP) ' atau
' Distress (EXP) '. Tidak ada pembatasan pada tanggal publikasi diberlakukan.
Untuk melengkapi pencarian elektronik, kami juga melakukan
pencarian dari daftar referensi dari ulasan sebelumnya, makalah kunci
on February 5, 2020 by guest. Protected by copyright.
dan artikel terkait lainnya diidentifikasi fi ed oleh pencarian elektronik.
Kami juga melakukan pencarian sistematis daftar isi jurnal kunci untuk
mengidentifikasi studi tambahan terjawab oleh pencarian elektronik.
seleksi studi
Judul dan abstrak awalnya dinilai untuk kelayakan. Jika hal itu
mungkin untuk con fi rm bahwa artikel memenuhi kriteria inklusi dari
sendiri abstrak, artikel teks lengkap itu diambil. Jika itu jelas dari
abstrak bahwa artikel itu tidak memenuhi syarat, itu ditolak segera.
Jika itu tidak mungkin untuk menentukan kelayakan sebuah artikel
dari abstrak, artikel teks lengkap itu diambil. Jika informasi kunci yang
hilang, kami menghubungi penulis untuk data yang hilang. Jika ini
tidak mungkin atau tidak efektif, studi itu ditolak, (lihat fi angka 1 ).

Gambar 1 PRISMA mengalir diagram.
ekstraksi data
The spesifik berikut fi Informasi c berkaitan dengan pengumpulan data
dan hasil diekstraksi secara individual dari masing-masing diidentifikasi fi Artikel
ed dan menandatangani Excel spreadsheet pradesain: tanggal dan
lokasi geografis dari pengumpulan data; maksud dan tujuan
pemeriksaan; belajar desain; peserta kriteria inklusi dan eksklusi;
prosedur rekrutmen; ukuran sampel; stadium penyakit; Status
sosiodemografi (umur, etnis dan hubungan, status pendidikan dan
pekerjaan); kalinya sejak diagnosis; komorbiditas tambahan;
tahap pengobatan
on-pengobatan atau pasca perawatan); perawatan yang dilakukan
(operasi, radioterapi, terapi hormon, kemoterapi, surveilans aktif (AS) /
menunggu waspada (WW)); kuesioner dimanfaatkan; analisis statistik
dilakukan; prevalensi depresi (%) dan prevalensi kecemasan (%). Untuk
menguji konsistensi ekstraksi data di seluruh studi, tiga peneliti (SW,
LL, SE) data yang diambil dari enam artikel yang dipilih secara acak
yang sama, kemudian dibandingkan hasil ekstraksi mereka. Sebuah
sistem poin dimanfaatkan untuk memungkinkan penilaian obyektif
konsistensi. Satu titik dialokasikan untuk variabel dengan ekstraksi data
identik dan 0 poin untuk variabel dengan perbedaan. Semua peringkat,
konsistensi berkisar antara 92% sampai 96% (median: 94%).
Watts S, Leydon G, Birch B, et al. BMJ Terbuka 2014; 4: e003901. doi: 10,1136 / bmjopen-2.013-003.901
Akses terbuka
BMJ Open: first published as 10.1136/bmjopen-2013-003901 on 13 March 2014. Downloaded from
http://bmjopen.bmj.com/
Prosedur meta-analisis
Mengingat berbagai perkiraan proporsi diharapkan dalam data
diekstrak, logits metode proporsi melakukan analisis statistik
dipekerjakan, bukan dari satu memanfaatkan pendekatan normal
distribusi binomial. Cochran ' s Q uji diaplikasikan pada logits untuk
menguji hipotesis homogenitas dari perkiraan dalam-studi tentang
proporsi, dengan nilai Q lebih besar menunjukkan bahwa perkiraan
tidak homogen. analisis awal disorot nilai Q antara Q = 15,2 dan 215,
on February 5, 2020 by guest. Protected by copyright.
dengan beberapa nilai yang lebih besar menunjukkan tingkat
heterogenitas, hasil dalam beberapa kasus hanya satu atau dua
(Pretreatment, penelitian berada di luar garis dengan yang lain. Untuk kelengkapan,
hasil meta-analisis telah disediakan bahkan untuk kasus-kasus di
mana heterogenitas jelas.
HASIL Hasil
Pencarian
Pencarian database elektronik yang awalnya menghasilkan 1778
referensi artikel jurnal. Dari jumlah tersebut, 1655 yang kemudian
dihapus karena baik duplikasi atau kegagalan untuk memenuhi
kriteria inklusi. artikel teks lengkap kemudian diambil dan kritis dinilai
untuk sisa
3
 Open Access

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123 referensi jurnal. Dari 123 artikel tersebut, 97 tidak memenuhi ukuran sampel penelitian

kriteria inklusi. 26 artikel sisanya dimasukkan ke dalam meta-analisis.
pencarian tangan jurnal kunci mengidentifikasikan fi ed oleh database
pencarian elektronik mengungkapkan tidak ada artikel jurnal
tambahan. Mencari daftar referensi dari artikel identifikasi fi ed melalui
database elektronik pencarian identi-
fi ed dua referensi artikel jurnal bunga yang telah dinyatakan telah
terjawab. artikel teks lengkap yang diambil untuk kedua referensi ini,
salah satu yang kemudian masuk ke dalam review saat ini, membuat
jumlah total studi termasuk 27 ( fi angka 1 ).
lokasi studi
Dari 27 penelitian masuk ke review, 9 dilakukan dalam Amerika, 6 - 15 4
di Australia 16 - 19 dan Belanda, 20 - 23 3 di Inggris, 24 - 26 2 masing-masing di
Swedia, 27 28
Jerman 29 30 dan Kanada 31 32 dan 1 di Finlandia. 33 Gambaran dari fitur
kunci dari setiap studi disertakan dapat dilihat di Tabel 1 .
Ukuran sampel penelitian masuk ke review bervariasi dari 36 ke 861.
Ukuran total sampel di semua 27 studi adalah 4494 dengan ukuran
sampel rata-rata
158. Ukuran sampel dari kelompok tahap perawatan individu
(pretreatment, on-pengobatan dan pasca perawatan) dapat dilihat pada Meja
2.
usia peserta
Data usia peserta dilaporkan oleh 24 dari 27 studi, dan dalam semua
24 kasus, usia rata-rata dilaporkan. Kisaran usia rata-rata di seluruh
24 studi bervariasi dari
57,5-73,2 tahun. Usia rata-rata semua peserta di seluruh 24 studi
adalah 66,3 tahun (3,3). Tiga studi gagal untuk melaporkan usia
peserta dalam format apapun. Usia rata-rata peserta di
masing-masing tiga kelompok perlakuan dapat dilihat pada Meja 2 .
kanker stadium
Data stadium kanker mengenai peserta dilaporkan oleh 23 dari 27
studi. Ada kurangnya konsistensi mengenai metode pelaporan.
Beberapa studi dimanfaatkan sistem T-pementasan klinis T1 (lokal)
ke T4

Tabel 1 Fitur utama dari studi termasuk

Sample Participant age

Penulis tahun Lokasi size Cancer stage Treatment stage

Ene 2006 Sweden 123 63.1 No data provided Pretreatment to Post-treatment

Pirl 2008 USA 50 62 Advanced Pre and On-treatment
Sharpley 2007 Australia 195 69.2 Localised Post-treatment
Bisson 2002 Wales 83 64.5 Mixed Pretreatment

http://bmjopen.bmj.com/
Dirkson 2009 USA 51 73.4 Mixed On-treatment
Dale 2009 USA 67 67.9 No data provided Pretreatment (but all participants had
received prior primary therapy)
Gabershagen 2007 Germany 115 64.1 Localised Pretreatment
Gabershagen 2009 Germany 84 62.8 Mixed Pretreatment to post-treatment
Hervouet 2005 Canada 861 67.9 Mixed Post-treatment
Monga 1999 USA 36 66 Localised Pretreatment to On-treatment to
Post-treatment
Monga 2005 USA 40 67.8 Localised Pretreatment to On-treatment to

on February 5, 2020 by guest. Protected by copyright.

Post-treatment
Pirl 2002 USA 45 69.4 Localised and On-treatment
Metastatic
Savard 2005 Canada 327 66 localised Post-treatment
Stone 2000 England 62 69 Mixed On-treatment
Soloway 2004 USA 103 62 No data provided Pretreatment
Steineck 2002 Finland 326 64.5 Localised Post-treatment
Symon 2006 USA 50 59.9 Localised Pretreatment to Post-treatment
Sharpley 2007 Australia 183 69.2 Localised Post-treatment
Sharpley 2009 Australia 150 69.8 Localised Post-treatment
van Tol-Geerdink 2006 Holland 118 70 Localised Pretreatment
Van den Berg 2009 Holland 129 64.9 Localised On-treatment (active surveillance)
Van den Berg 2010 Holland 129 64.6 Localised On-treatment (active surveillance)
Monga 2001 USA 40 67.6 Localised Pretreatment to Post-treatment
Korfage 2006 Holland 299 65.4 Mixed Pretreatment Post-treatment
Bitsika 2009 Australia 381 No data Localised Post-treatment
Nordin 2001 Sweden 118 No data Localised & Advanced Pretreatment
Burnet 2007 England 329 68.8 Localised On-treatment and post-treatment

4 Watts S, Leydon G, Birch B, et al. BMJ Open 2014; 4: e003901. doi:10.1136/bmjopen-2013-003901

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Table 2 Overview of study characteristics

Posttreatment
All studies Pretreatment On-treatment studies
studies studies

Study samples (patient numbers) 4494 1707 723 3087

Participant ages 66.3 (3.3) 64.8 (2.9) 67.6 (3.3) 66.9 (2.4)
Number of patients with localised PCa 3270 1299 563 2236
Number of patients with advanced PCa 513 162 72 441
Number of patients with metastatic PCa 87 58 40 7
PCa, prostate cancer.

(metastatic) while the majority simply graded PCa as localised,
advanced or metastatic. No study reported the patient disease
stage using the recommended
tumour-nodes-metastasis (TNM). The majority of patients had been
diagnosed with localised disease (n=3270), followed by advanced
(513) and metastatic PCa (87), as shown in table 2 .
Cancer treatments undertaken
Table 3 provides an overview of the number of participants
undergoing each PCa treatment. Unfortunately, it was not possible to
stratify the treatments undertaken as a function of either disease
stage (localised, advanced or metastatic) or treatment stage
(on-treatment or posttreatment). This was because in many instances
patients with different disease staging or who were at different
treatment stages were recruited into the same cohort. Consequently,
while the number of patients completing each type of treatment was
clearly highlighted, it was not possible to determine whether the
patients with localised, advanced or metastatic disease, or those who
were either currently undergoing treatment or had fi nished treatment,
Meta-analysis of depression and anxiety prevalence
Number of studies reporting depression
Twenty-six of the 27 studies entered into the review reported data on
depression prevalence. Of these 26, 13 reported depression in
pretreatment patients, 9 in on-treatment patients and 13 in
post-treatment patients. The number of total studies from the 3 groups
exceeded 27 as several longitudinal studies reported depression in
multiple treatment groups (ie, in pretreatment and on-treatment
groups).
Number of studies reporting anxiety
Twenty of the 26 studies entered into the review reported data on
anxiety prevalence. Of these 20, 9 reported anxiety
in pretreatment patients, 4 in
on-treatment patients and 11 in post-treatment patients.
Number of patients measured for depression
Collectively, measures of depression were recorded from 5139
participants across the 26 studies. In terms of the individual treatment

http://bmjopen.bmj.com/
had completed them. Thus, the data in table 3 provide a collective
groups, 1259 participants provided measures of depression in the
overview of the treatments undertaken by all of the patients,
pretreatment group, 723 in the on-treatment group and 3157 in the
irrespective of disease or treatment stage. In addition, several of the
posttreatment group.
pretreatment studies recruited participants who had yet to decide on
treatment. Such patients are listed in table 3 as ‘ newly diagnosed ’.

Number of patients measured for anxiety

Collectively, measures of anxiety were recorded from 4635

on February 5, 2020 by guest. Protected by copyright.

Questionnaires analysis
Of the 12 questionnaires meeting the questionnaire inclusion criteria
as listed in the method section, only 7 were utilised by the 27 studies
entered into this meta-analysis. Table 4 lists the seven
questionnaires, the frequency with which they were used and the
clinical cut-off scores utilised to determine caseness.
participants across the 20 studies. In terms of the individual treatment
groups, 1057 participants provided measures of anxiety in the
pretreatment group, 501 in the on-treatment group and 3077 in the
post-treatment group.
Pretreatment depression and anxiety prevalence
Depression: within the 13 studies that provided measures of
depression in patients with PCa prior to undergoing

Table 3 The number of prostate cancer patients being treated and undertaking each treatment modality

Hormone Therapy Newly diagnosed (no

Radical Radiotherapy (EBRT & (orchiectomy and ADT) Active surveillance or treatment yet selected)
prostatectomy brachytherapy) Chemotherapy watchful waiting

924 1578 264 24 418 304

ADT, androgen deprivation therapy; EBRT, external beam radiotherapy.

Watts S, Leydon G, Birch B, et al. BMJ Open 2014; 4: e003901. doi:10.1136/bmjopen-2013-003901 5

 Open Access

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Table 4 Questionnaires utilised, frequency of use and cut-off scores utilised

Questionnaire name Frequency of use Clinical cut-off scores utilised

Hospital anxiety and depression scale (HADS) 13 HADS-A: ≥ 8

HADS-D: ≥ 8
Beck depression inventory (BDI) 6 ≥ 10
Self rating anxiety scale (SAS) 4 ≥ 36
Self rating depression scale (SDS) 4 ≥ 40
Centre for epidemiologic studies depression scale (CES-D) 4 ≥ 15
Stait-Trait Anxiety Scale (STAI) 4 ≥ 44
Memorial anxiety scale for prostate cancer (MAX-PC) 3 ≥ 27

treatment (see fi gure 2 ), the prevalence of depression was 17.27% (CI
15.06% to 19.72%).
Anxiety: Within the nine studies that provided measures of anxiety
in patients with PCa prior to undergoing treatment (see fi gure 2 ), the
prevalence of anxiety was
27.04% (CI 24.26% to 30.01%).
On-treatment depression and anxiety prevalence
Depression: Within the nine studies that provided measures of
depression in patients with PCa currently undergoing treatment (see fi gure
3 ), the prevalence of depression was 14.70% (CI 11.92% to 17.99%).
Anxiety: within the four studies that provided measures of anxiety in
patients with PCa currently undergoing treatment (see fi gure 3 ), the
prevalence of anxiety was 15.09% (CI 12.15% to 18.60%).
Post-treatment depression and anxiety prevalence
Depression: within the 13 studies that provided measures of
depression in patients with PCa who had completed treatment (see fi gure that clinical decisions have been based
Our fi ndings suggest that over the trajectory of the PCa journey,
depression and anxiety prevalence are highest in patients who have
yet to undergo treatment (17.27% and 27.4%, respectively), lowest in
patients who are currently undertaking treatment (14.70% and
15.90%, respectively) before rising again in patients who have
completed treatment (18.44% and 18.49%, respectively). The
relatively small variation observed within these prevalence rates
across the different treatment stages, along with the large collective
sample size of the meta-analysis (4494), suggests that these
conclusions are valid, powerful and robust summaries of the data
available. The prevalence of clinical depression and anxiety in British
men aged over 65 years is estimated to be less than 9% and 6%,
respectively. 34 Such data are in stark contrast to the prevalence
reported in patients with PCa of the same age in this study. The
current meta-analysis is the fi rst of its kind to speci fi cally assess the
prevalence of clinical depression and anxiety in patients with PCa
over their treatment spectrum, from pretreatment, through treatment
to posttreatment follow-up. Until now, the lack of synthesis of the
available data relating to depression and anxiety in PCa has meant

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4 ), the prevalence of depression was 18.44% (CI 15.18% to 22.22%).

Anxiety: within the 11 studies that provided measures of anxiety in

patients with PCa who had completed treatment (see fi gure 4 ), the
prevalence of anxiety was
18.49% (CI 13.81% to 24.31%).

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Depression and anxiety prevalence across and within treatment
groups
Figure 5 provides a pictorial representation of the prevalence of
depression and anxiety both within and across each of the three
treatment groups.

DISCUSSION
There is a real need within clinical oncology, particularly as the burden
of disease is escalating with improved diagnosis and treatment, for an
increased awareness about the issue of psychological distress among
men diagnosed with, being treated for and surviving through/living
with a PCa diagnosis. The results of the current meta-analysis go
some way in addressing this issue by providing those working within
the fi eld of PCa with a rigorous overview of the likely prevalence of
depression and anxiety in the patients they treat.
Figure 2 Pretreatment depression and anxiety % prevalence.

6 Watts S, Leydon G, Birch B, et al. BMJ Open 2014; 4: e003901. doi:10.1136/bmjopen-2013-003901


Figure 3 On-treatment depression and anxiety % prevalence.
on isolated research trials that lack suf fi cient power and depth in
terms of sample sizes, treatment protocols and treatment stages.
Consequently, the true prevalence of psychological morbidity
experienced by patients with PCa across the treatment spectrum is
poorly understood and described and this may result in patients being
left untreated.
We hope that with additional epidemiological investigation we will
be able to offer a more risk adapted approach with more intensive
screening and support being offered to individuals who are most at
risk of psychological morbidity, which may in part be related to
Figure 4 Post-treatment depression and anxiety % prevalence.
Watts S, Leydon G, Birch B, et al. BMJ Open 2014; 4: e003901. doi:10.1136/bmjopen-2013-003901
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their current stage of treatment. This is important as research
suggests that patients with cancer who are suffering from clinical
depression and anxiety are less likely to adhere to their treatment plan
and are more likely to experience adverse reactions to their treatment. 4
5
Indeed, recently published research has speci fi cally highlighted the
negative impacts of PCa speci fi c anxiety on post-treatment
survivorship in the form of poorer sexual function and increased
depressive symptomology, further supporting the need for effective
and timely intervention. 35
Consequently, the identi fi cation, treatment and management of
concurrent psychological distress should be a key clinical objective as
a means of enhancing clinical outcomes and patient QoL. Identifying
which stage of treatment patients with PCa are most likely to
experience such conditions is an important fi rst step to achieving this.
There are several limitations to the results generated by this review
that need to be noted when interpreting the fi ndings. There is a
noticeable dearth of research into the prevalence of depression and
anxiety in patients with PCa with metastatic disease; we identi fi ed
only 87 patients with metastatic PCa out of the pooled sample size of
4494. Given the increased physical symptomology, and signi fi cantly
lowered life expectancy, associated with metastatic PCa, it is possible
that the prevalence of psychological morbidity within this patient
cohort will probably be substantially higher. Unfortunately, it was not
possible to generate depression and anxiety prevalence data speci fi cally
for men with metastatic disease, as the studies that recruited patients
with PCa with metastatic disease did so as part of larger collective
samples of patients that included those with localised and/or
advanced PCa. In the majority of cases, no individual depression and
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anxiety data were provided speci fi cally for those with metastatic
disease. Consequently, it was not possible to describe these patients
separately. We do not know the overall proportion of men who suffer
from some psychological distress during their PCa cancer journey
from these largely cross-sectional studies.
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Figure 5 Depression and anxiety % prevalence across treatments.
7
 Open Access
We suspect that a number of individuals become depressed and
anxious at various stages of their cancer journey and then may
improve, so overall the numbers of people affected at some stage
may be higher than we are able to identify from this analysis. We
would need to conduct a sustained longitudinal cohort study to resolve
this question. Likewise, none of the included studies provided any
form of data relating to the patients ’ history of depression and anxiety.
Consequently, it was not possible to determine whether a history of
depression and anxiety acted as a signi fi cant predictor of current
depression and anxiety.
Furthermore, this study did not compare the depression and anxiety
prevalence rates generated directly to that observed in a cohort to
healthy men or men with other cancers. As a consequence, we were
unable to speci fi cally determine how PCa and its treatment impacted
on the prevalence of psychological distress observed. The essentially
descriptive nature of this study therefore needs to be noted.
It is also important to note the wide variability in the point
prevalence estimates of anxiety and depression and the 95% CIs
associated with them. There are likely to be many reasons for this
variability, which include sample size, the differing instruments that
have been used to measure depression and anxiety, selective
populations and post-treatment outcomes. For example, it is possible
that depression and anxiety prevalence in postprostatectomy patients
would vary substantially depending on factors such as positive or
negative margin status. Unfortunately, it was not possible to formally
investigate the properties of the populations to determine whether
there were any such differences that would explain this variability.
This represents an important limitation to the
fi ndings of this study. It is important that future studies into the
assessment of depression and anxiety in this patient group carefully
identify the characteristics of their populations to address this issue.
We were also not able to determine whether the prevalence of
depression and anxiety was a factor in fl uencing the type of PCa
treatments provided to individuals. The associated side effects of PCa
treatment include debilitating urinary, sexual and bowel dysfunction as
well as the potentially negative psychological side effects of passive
treatment options such as AS and WW, in which the patient faces
living with a diagnosed but untreated cancer. This is an important
clinical issue as it may provide a novel avenue in which to streamline
the screening of depression and anxiety by offering patients
undertaking treatments that have been shown to induce higher rates
of distress with early, preventive support during their cancer journey.
Burnet et al 27 reports that the prevalence of depression among
AS/WW patients is just 4% (in a sample of 100 patients recruited from
a single cancer centre of international excellence), leading the authors
to conclude that AS does not predispose patients to higher levels of
distress in comparison to those undergoing
8 Watts S, Leydon G, Birch B, et al. BMJ Open 2014; 4: e003901. doi:10.1136/bmjopen-2013-003901
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radical treatment. However, our data identi fi ed that the prevalence of
depression is almost three times higher than that reported by Burnet et
al 27 at 11% (within this speci fi c population, suggesting that
psychological distress may indeed be a substantial risk associated
with AS/WW. The utilisation and uptake of AS/WW within the UK is
increasing, 36 yet our results clearly highlight that the issue of
psychological morbidity among these patients with PCa is poorly
described and de fi ned, with only 4 of the 27 studies entered into this
review obtaining measures of depression and anxiety from this patient
population. 21 22 26 33 Consequently, we suggest that patients being
treated with AS/WW should be investigated in more detail to better
understand the psychological rami-
fi cations of this form of management. Such research should ideally
involve the recruitment of larger sample sizes (>200) from multiple
sites to provide a more generalisable estimate of psychological
distress from this patient cohort.
In conclusion, across the treatment spectrum, patients with PCa
appear to experience a moderate to high degree of psychological
morbidity ranging from 15% to 27%. Most acute prevalences of
depression and anxiety occur prior to and after the completion of
treatment, the consequences of which may go on to negatively impact
on treatment compliance, 6 increased periods of hospitalisation 5 and
overall functional QoL. 37 Based on our fi ndings, we conclude that the
assessment, diagnosis and treatment of depression and anxiety
should be a key priority for any clinical oncology team working with
PCa to enable them to optimise their patients ’ QoL and clinical
treatment outcomes.
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Contributors SW was involved in protocol development, data searching, extraction and
analysis. PP was involved in statistical analysis. LL and SE were involved in data extraction.
Funding This work was supported by the National Institute for Health Research School of
Primary Care Research, grant number 73.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional unpublished data from this study are available.
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Open Access This is an Open Access article distributed in accordance with the Creative Commons
Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix,
adapt, build upon this work noncommercially, and license their derivative works on different terms,
provided the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/3.0/
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